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Managed care hospital report cards may not allow for differences among patients

Many managed care organizations (MCOs) now impose financial penalties on providers who appear to use excessive medical services in treating their patients. However, "excess" is difficult to define without assessing the severity of patient illness. In fact, when MCO hospital report cards don't take into account differences in patient severity of illness, such report cards may be misleading, concludes a study supported by the Agency for Health Care Policy and Research (HS07322). For example, a hospital that uses more blood transfusions for patients undergoing hip fracture surgery may have a higher proportion of severely anemic patients than another hospital that uses fewer transfusions for otherwise similar patients.

MCO report cards that discount severity of illness may hurt hospitals that appear to have high use of health services but actually have low use (given the illness severity of their patients), while rewarding hospitals for use that appears low but is actually high (given the low illness severity of their patients), explains Jeffrey L. Carson, M.D., the study's principal investigator. Dr. Carson and his colleagues retrospectively studied the medical charts of 8,776 hip fracture patients 60 years of age and older who underwent surgical hip repair at 1 of 19 study hospitals located in four States between 1982 and 1993. The researchers examined transfusion rates among hospitals, which patient characteristics were associated with transfusion, and whether those characteristics varied among hospitals.

The results showed that postoperative transfusion rates varied from 31 percent to 54 percent of hip fracture patients among study hospitals. Without adjustment for hospital differences in patient severity of illness, four of nine teaching hospitals and two of nine nonteaching hospitals had transfusion rates significantly higher than the reference hospital, while one nonteaching hospital had a lower rate. After adjusting for patient anemia and other clinical variables, one of nine teaching and four of nine nonteaching hospitals had rates higher than the reference hospital, while four teaching hospitals and one nonteaching hospital had lower rates.

Details are in "How you look determines what you find: Severity of illness and variation in blood transfusion for hip fracture," by Roy M. Poses, M.D., Jesse A. Berlin, Sc.D., Helaine Noveck, M.P.H., and others, in the American Journal of Medicine 105, pp. 198-206, 1998.

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